Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative

In 2005, local leaders in New York City developed the Washington Heights/Inwood Network for Asthma Program to address the burden of asthma in their community. Bilingual community health workers based in community organizations and the local hospital provided culturally appropriate education and support to families who needed help managing asthma. Families participating in the yearlong care coordination program received comprehensive asthma education, home environmental assessments, trigger reduction strategies, and clinical and social referrals. Since 2006, 472 families have enrolled in the yearlong program. After 12 months, hospitalizations and emergency department visits decreased by more than 50%, and caregiver confidence in controlling the child''s asthma increased to nearly 100%. Key to the program''s success was the commitment and involvement of community partners from program inception to date.

KEY FINDINGS

• ▪Community health workers who are based in local community-based organizations and have strong ties to the community that they serve are uniquely positioned to initiate and nurture trusting partnerships with program participants.
• ▪Community health workers can move fluidly between the community and the health care settings, bridging gaps in care, providing culturally appropriate education and services, and connecting families to the clinical and social resources they desperately need.
• ▪The strength and success of the Washington Heights/Inwood Network (WIN) for Asthma Program is based in large part on the commitment and active involvement of community partners from program inception to date as well as the frequent exchange of program information and ideas among all partners and staff.
• ▪This hospital–community care coordination model is applicable to other populations and disease areas because of its customizable, culturally sensitive, and holistic approach to education and support.

     

Informing Neighborhood Health

ABSTRACT

The purpose of the Informing Neighborhood Health project is to facilitate access to electronic health information resources at select community faith-based clinics. The project partners Texas Woman's University, Houston Academy of Medicine-Texas Medical Center Library, and five community faith-based clinics located in Houston, Texas, that primarily serve the homeless and working poor. The clinics include San Jose Clinic, Good Neighbor Healthcare Center, Eastwood Health Clinic, the Children's Clinic at Northwest Assistance Ministries, and Bering Omega Community Services. The Informing Neighborhood Health project placed Internet-connected workstations at each participating clinic. The project also provided training for select clinic staff members that focused on a variety of electronic health information resources. A post-training evaluation was administered at the end of each training session. In addition, site visits and interviews were conducted at each participating clinic once project workstations were operational and staff members had attended training sessions. A final project focus group was conducted with administrators from each participating clinic. Clinic staff members have incorporated use of project workstations into existing workflow processes and are using electronic information resources to make better informed health care decisions for their clients.     

Genesee County REACH Windshield Tours: Enhancing Health Professionals Understanding of Community Conditions that Influence Infant Mortality

The Genesee County Racial and Ethnic Approaches to Community Health (REACH) program is a community-based program designed to reduce African American infant mortality rates in Flint, Michigan. Genesee County REACH activities address three core themes: fostering community mobilization, reducing racism, and enhancing the maternal–infant health care system. The REACH Community Action Plan was generated using a community-based participatory approach, and is based on a socio-ecological model with interventions focused at the individual, organizational, health system, and community levels. Genesee County REACH’s Community Windshield Tours were developed to raise awareness of social and environmental barriers to health promotion among health care system staff in Flint, Michigan. These tours provide a close-up examination of the community’s environmental conditions and the experiences of mothers, children, and families at risk for poor birth outcomes. In this article, we report our findings from pre-/post-tour surveys, as well as long-term follow-up surveys, to assess the impact of this REACH activity on participants’ knowledge and beliefs about Genesee County residents, and to determine any resultant individual, policy, system, or environmental changes. We used t tests to compare participants’ responses before and after the tours. We found that several individual- and systems-level changes have resulted from these tours, reflecting greater cultural sensitivity and increased understanding of patients’ circumstances. African American infant mortality rates in Genesee County declined to a historic low in 2005, and they remain lower than in previous years. Although REACH coalition partners recognize that this reduction cannot be attributed to a single intervention or activity, REACH activities such as the Community Windshield Tours addressing multiple levels of the socio-ecological model may have had a synergistic effect.     

Healthy Homes: In-Home Environmental Asthma Intervention in a Diverse Urban Community

Objectives. We evaluated health outcomes associated with in-home interventions in low-income urban households with children with asthma.Methods. A comprehensive health and environmental assessment and subsequent intervention were completed in 116 households with 170 enrolled children with asthma. Home health workers provided household safety, asthma prevention education, and targeted environmental intervention to decrease asthma triggers and improve household safety. We collected environmental data with questionnaire and dust samples and health information with a questionnaire incorporating the American Academy of Pediatrics Children’s Health Survey for Asthma and other instruments at baseline and at follow-up 11 to 12 months later to evaluate the impact of the intervention on the health of the child and family in Lowell, Massachusetts, from September 2009 to January 2012.Results. The diverse study population of low-income children showed a statistically significant health improvement from baseline to follow-up. The cost of the interventions (not including personnel) was $36 240, whereas the estimated medical savings over a 4-week assessment period was $71 162, resulting in an estimated annual savings of about $821 304.Conclusions. Low-cost, multicomponent interventions decrease all measures of asthma severity and health care utilization in a diverse population of urban children.The Lowell Healthy Homes Program in Massachusetts targeted asthma, the most common chronic childhood disease. Asthma has many known indoor environmental triggers, including dust, pests, smoke, and pets. Children are particularly vulnerable to home hazards and may develop lifelong health problems because of their home environment.1 In-home interventions to decrease triggers of childhood asthma involving remediation and education provided by community health workers has been reported.2–4 The federal government funded this initiative in Lowell, Massachusetts, in part because of its diverse demographic urban communities that have old, substandard housing and associated health risks. The project goal was to reduce the asthma burden and improve health outcomes for children with asthma and their families through home environmental assessments and individualized interventions focused on reducing indoor allergen levels and asthma triggers.Massachusetts is located in the Northeast, where asthma rates are higher than are those in other regions of the United States.5 Lowell schoolchildren’s asthma prevalence (13.0%) is higher than the statewide average (10.9%).6The 2010 US Census showed that Lowell’s population was 106 519, of which 47.2% were minority residents and 11.3% were of Puerto Rican descent (the largest subset of the 17.3% Hispanic residents).7 According to the National Health Statistics report on asthma prevalence in the United States, those of Puerto Rican descent have the highest asthma rate, twice the rate of the general population (16.6% vs 8.2%).5 The local and state rates for emergency department discharges and inpatient hospitalizations for asthma reveal that the hospitalization rate for Lowell’s children with asthma is almost twice the state average for the composite years 2006 to 2008.8The University of Massachusetts, Lowell directed this community intervention with local collaborators, including a federally funded community health center, housing authority, community development corporation, multiservice community action agency, and first-time home buyers education program. The project drew on our team’s unique experience in developing cross-cultural healthy home interventions to improve the quality of housing in Lowell through a multitrigger, multicomponent, personalized home environmental intervention with home health assessment workers (HHAWs) and an environmental assessor.     

Community Health Monitoring: Taking the Pulse of America's Children

Objective: To describe the development, content, enablers/barriers, and impact of child health reports in nine communities participating in the Robert Wood Johnson Foundation funded Child Health Initiative (1991–1996). Methods: A qualitative, prospective, multiyear, longitudinal evaluation using a multiple case-study methodology. Three waves of structured in-per-son and telephone interviews of the project staff, community leaders, and key participants tracked the development of child health reports in all nine communities. A mailed survey of project directors was administered to assess accomplishments at the completion of the project. Content analysis of each community health report was conducted using different conceptual frameworks for health measurement and reporting. Results: All communities succeeded in creating a report that contained a broad set of outcome indicators reflecting children's health and well-being. The process of creating these reports, their content, level of analysis, presentation formats, and dissemination varied across sites based on available resources, data and analysis capacity, and other political considerations. While commonly accepted outcome measures were used in most reports (e.g., infant mortality, teen births, immunization rates), process indicators, important for quality monitoring and community health improvement, were notably lacking. In each community the reports were credited with providing a more comprehensive and integrated view of the health needs of children. Conclusions: Additional conceptual and technical work is needed to improve the ability of community health reports to capture key indicators of interest. Community reports can serve an important role in building the consensus needed to create program and policy changes. Community reports may have additional utility in monitoring the impact of health systems change on population health. Community reports can also facilitate a shared learning process for the participants and the community, and can be a useful tool to advance a children's health policy agenda.     

The Most Important Skills Required by Local Public Health Departments for Responding to Community Needs and Improving Health Outcomes

In 2017, Public Health 3.0 was introduced, providing recommendations that expand traditional public department functions and programs. Operationalizing the framework requires that local health departments invest in the requisite professional skills to respond to their community’s needs. The purpose of this paper is to determine the professional skills that are most important for local health departments to respond to large public health issues and challenges that are having a major impact on their communities. The study used a cross-sectional assessment of the education and training needs of local public health departments in Nebraska following the principles of practice-based systems research. The assessment was designed to assess the training and education needs of local health department staff members. The questions measured the perceived importance of and respondent’s capacity across 57 core competencies for public health professionals modified from the Council on Linkages Between Academia and Public Health Practice. A total of 104 staff members from seven local health departments were requested to complete the assessment and 100% of the individuals responded to and completed the assessment. Twenty-eight skills were identified as the most important skills needed for local health departments. The skills were themed and categorized into four domains. (1) Data, Evaluation, and Quality Improvement, (2) Community Engagement and Facilitation, (3) Systems Thinking and Leadership, and (4) Policy and Advocacy. The results from this analysis provide direction to strengthen and transform the public health system into one that is connected, responsive, and nimble. Additionally, it also highlighted a glaring omission that Equity, Diversity, and Inclusion should be included as the fifth domain.

     

Community Engagement and Data Disclosure in Environmental Health Research

Summary: Federal funding agencies increasingly support stakeholder participation in environmental health studies, and yet there is very little published research on engagement of community members in the development of data disclosure (DD) strategies. The Ohio Environmental Protection Agency reported airborne manganese (Mn) concentrations in East Liverpool, Ohio, 30 times higher than the reference concentration, which led to an academic–community research partnership to address community concern about Mn exposure, particularly among children. Children and their families were recruited to participate in a pilot study. Samples of blood and hair were collected from the children and analyzed for metals. DD mechanisms were developed using an iterative approach between community and academic partners. Individual DD letters were mailed to each participating family, and a community meeting was held. A post-meeting survey was administered to gauge community perception of the DD strategies. The purpose of this article is to demonstrate the effectiveness of engaging community partners in the conduct of environmental health research and in the development of DD strategies for individuals and the community at large. Scientists should include community partners in the development of DD strategies to enhance translation of the research findings and support the right of study participants to know their individual results.     

新疆精河县社区健康教育工作中存在问题及对策分析

健康教育是医学模式转变和现代医学发展的必然趋势.随着新医改的进一步深化,基本公共卫生服务逐步均等化工作已经在城乡逐渐铺开.社区已经成为推行健康教育与健康促进的重要场所.社区健康教育是利用社区资源针对不同人群开展的健康教育活动与过程.对社区居民、患者及其家属开展健康教育与健康促进,通过健康教育和环境支持改变人们的行为、生活方式和社会的影响,提高人民群众健康意识和自我保健能力、防治疾病能力.养成积极向上的健康行为,消除患者及其家属的不良心理反应,帮助他们树立战胜疾病的信心,实现对患者的心理保健,促使人们采纳有益于健康行为的生活方式.社区健康教育对于提高居民的健康水平和文明素质具有重要的作用.     

安徽省城市社区卫生服务的现状调查

社区卫生服务在我国城市已历经八年的发展，取得了长足的进步，然而各地的发展速度和规模很不平衡。文章基于安微省城市社区卫生服务的现状调查，在与全国进行比较分析后指出：安徽省城市社区卫生服务的发展过程中，政府、卫生服务人员、居民对社区卫生服务的认识，卫技人员的素质和能力，经济补偿机制以及社会支持力度等问题尤为突出，亟需改善；并进一步强调了社区卫生服务是一项复杂的系统工程，它不仅需要社区卫生服务这个系统内部各要素的相互协调和作用，更需要有外部相关系统的支持。     

Ethnographically Informed Community Evaluation: A Framework and Approach for Evaluating Community-Based Initiatives

Objectives: This paper describes ethnographically informed community evaluation (EICE), a framework for evaluating complex community-based interventions, and illustrates its use in the evaluation of Baltimore City Healthy Start, a federally funded infant mortality prevention project. EICE, which is influenced by cultural anthropology and assets-based community assessment, supports continuous program improvement, resident involvement, and measurement of community-level change. This approach takes into account both individual and contextual levels of analysis. Methods: The evaluation coupled a participatory approach with qualitative and survey research methods to study community context and how it might contribute to infant mortality and influence program implementation, and to assess community change resulting from the program. Data collection included focus groups, key informant interviews, surveys, neighborhood mapping, journaling, and a study of community problem-solving. Results: The evaluation provided program-related feedback to staff, contributed to a collective understanding of the local context, validated and augmented outcome findings, and imparted skills and a sense of empowerment to the neighborhood. Results reveal a community burdened by crime and social problems, yet showing great diversity in physical and social conditions when examined at the census block group level. Nevertheless, these social and physical hazards in the community are more salient than any specific health issue such as infant mortality. Conclusions: EICE is a powerful evaluation approach able to respond to the complexities of community-based maternal and child health initiatives designed to institute changes across multiple domains. EICE may be used, in whole or in part, as a supplement to traditional designs.     

Community participation for perinatal health in Istanbul

This study aimed to evaluate the success of a project in achieving community participation in efforts to improve perinatal health. A 10-step structured process was used to work with a community in Istanbul, Turkey. To evaluate the success of the project in achieving community participation, five key indicators were selected: (i) participation of the community group in decision making; (ii) gains in knowledge and skills of the community group; (iii) continuity of the community group; (iv) continuation of the health program by the community group; and (v) initiation of new support and advocacy activities. From the beginning, community members participated in all decisions regarding the group activities. In the early months, project staff had more of a guiding role, but, over time, the community members became active decision-makers. Over the course of the project they learned how to identify community health problems, and to design, implement and evaluate interventions to address those problems. Four years later, meetings and activities of the group are continuing. The antenatal education course developed by the group continues to be offered at a local community centre. Community members are now completely responsible for promoting the course, communication with participants, planning the courses, making preparations for the sessions, as well as teaching non-technical topics. Course participants have developed ongoing support networks and have begun to advocate for better perinatal health services in the community. Working with a community is an intensive, time-consuming process. The results of this project indicate that the benefits, both in terms of health outcomes and in terms of increases in community capacity, can be well worth the effort.     

Health in Khulais villages, Saudi Arabia

A field work project was conducted in Khulais villages by the Department of Community Medicine, Riyadh Faculty of Medicine, in February 1977. The project involved jointly Riyadh University and the Saudi Arabian Ministry of Health, as well as other organizations. Over a 10-day period, twenty-five students of the fourth-year medical class under the supervision of seven members of the staff studied health problems and rendered selected health services to the community.
Project activities included a study of a sample of 280 schoolchildren by clinical examination, anthropometric measurement and selected laboratory investigations; a house-to-house survey; a study of the epidemiology of schistosomiasis and malaria; immunization of pre-school children; a health education programme and an evaluation of the health centre's activities.
The main objective was to give the students an appreciation of the need for team-work in approaching community health and help to cultivate their interest in community medicine as an applied discipline.     

Involving Local Health Departments in Community Health Partnerships: Evaluation Results from the Partnership for the Public’s Health Initiative

Improving community health “from the ground up” entails a comprehensive ecological approach, deep involvement of community-based entities, and addressing social determinants of population health status. Although the Centers for Disease Control and Prevention, the Office of the Surgeon General, and other authorities have called for public health to be an “inter-sector” enterprise, few models have surfaced that feature local health departments as a key part of the collaborative model for effecting community-level change. This paper presents evaluation findings and lessons learned from the Partnership for the Public’s Health (PPH), a comprehensive community initiative that featured a central role for local health departments with their community partners. Funded by The California Endowment, PPH provided technical and financial resources to 39 community partnerships in 14 local health department jurisdictions in California to promote community and health department capacity building and community-level policy and systems change designed to produce long-term improvements in population health. The evaluation used multiple data sources to create progress ratings for each partnership in five goal areas related to capacity building, community health improvement programs, and policy and systems change. Overall results were generally positive; in particular, of the 37 partnerships funded continuously throughout the 5 years of the initiative, between 25% and 40% were able to make a high level of progress in each of the Initiative’s five goal areas. Factors associated with partnership success were also identified by local evaluators. These results showed that health departments able to work effectively with community groups had strong, committed leaders who used creative financing mechanisms, inclusive planning processes, organizational changes, and open communication to promote collaboration with the communities they served. Cheadle is with the Department of Health Services, University of Washington, Seattle, WA, USA; Hsu, Pearson, and Beery are with the Center for Community Health and Evaluation, Seattle, WA, USA; Schwartz is with the Kaiser Foundation Health Plan and Hospitals, Oakland, CA, USA; Greenwald is with the School of Policy, Planning, and Development, University of Southern California, Los Angeles, CA, USA; Flores is with the The California Endowment, San Francisco, CA, USA; Casey is with the Partnership for the Public’s Health, Oakland, CA, USA.     

Interorganizational Network Changes Among Health Organizations in the Brazos Valley, Texas

Community health development is a process by which a community identifies factors influencing population health, assesses available resources to build the capacity to plan and take action, and implement interventions to address identified needs. At its core, community health development targets structural change and infrastructure development to facilitate more efficient and effective health service delivery systems and environmental changes to support improvements in community health. One indicator of structural change and common measure of community capacity is the relationships among the network of organizations that comprise that system. The Brazos Valley has employed a community health development approach to population health improvement in partnership with the Center for Community Health Development. Changes in interorganizational networks illustrate progress in the Brazos Valley. Contextual factors provide some insight into how the process has unfolded.     

Peer Reviewed: Community Health: A Critical Approach to Addressing Chronic Diseases

Many public health solutions to chronic diseases involve individual lifestyle choices: eating more healthfully, increasing physical activity, and quitting smoking. This approach neglects barriers in the community environment that make modifying unhealthy behaviors challenging. Addressing environmental barriers is an essential strategy to supporting behavioral changes. Changing community environments that contribute to unhealthy behaviors can improve community health.

Community indicator reports can be used to strengthen community environments for optimum health. The reports are comprehensive evaluations of community well-being that reflect community factors that influence health. Prevention Institute studied community indicator reports for The California Endowment and produced Good Health Counts: A 21st Century Approach to Health and Community for California. This commentary on that document highlights recommendations for the use of community indicator reports.

     

Peer Reviewed: Charting the Future of Community Health Promotion: Recommendations From the National Expert Panel on Community Health Promotion

In the decades since chronic illnesses replaced infectious diseases as the leading causes of death, public health researchers, particularly those in the field of health promotion and chronic disease prevention, have shifted their focus from the individual to the community in recognition that community-level changes will foster and sustain individual behavior change. The former emphasis on individual lifestyle change has been broadened to include social and environmental factors, often without increased resources. To find new ways to support community health promotion at the national level, the National Center for Chronic Disease Prevention and Health Promotion and the Division of Adult and Community Health invited an external panel of experts to participate in the National Expert Panel on Community Health Promotion. This article highlights the process through which the expert panel developed its eight recommendations. The recommendations include issues related to community-based participatory research and surveillance, training and capacity building, new approaches for health and wellness, and changes in federal investments. They illustrate the steps needed to broaden the traditional scope of public health and to advance a new vision for improving community health and wellness.     

Systems collaborate for a healthier community. A Community Health Advisory Board focuses on immunization

The Community Health Advisory Board (CHAB), Pierce County, WA, involves four healthcare systems--Franciscan Health System, MultiCare Medical Center, Group Health Cooperative of Puget Sound, and Good Samaritan Hospital--that have joined forces with other providers in an innovative attempt to better serve their community. An evaluation by representatives of New York University's Hospital Community Benefit Standard Program prompted St. Joseph Medical Center, Tacoma, WA, to bring major providers together in a coordinated effort that could reach community residents in need. At their first meeting in November 1992, CHAB members agreed on a purpose: to facilitate collaboration between healthcare providers throughout the county to develop programs and services that improve the health status of community residents. In January 1993 CHAB members selected a "quick success" project: a program aimed at increasing immunization levels to 90 percent for two-year-old children in the county. In February 1993 CHAB members committed the "best and brightest" to the Immunization Task Force, naming experts in planning, nursing, community health, education, and marketing. When the Immunization Task Force assessed the project, they realized that the "quick success" program would not be accomplished so quickly. CHAB has had to address underlying problems to make higher immunization levels sustainable. In March 1994 members will evaluate the immunization program's process, status, and structure; data on immunization levels; and the group's demonstrated ability to cooperate.